Claims Specialist

About the role

The Claims Specialist is responsible for following up directly with commercial and governmental payers to resolve billing issues and secure appropriate reimbursement in a timely manner. This individual identifies and analyzes denials and payment variances and enacts corrective measures as needed to effectively communicate and resolve payer errors.

Job duties and responsibilities

• Examines denied and underpaid claims to determine reasons for discrepancies
• Communicates directly with payers to follow up on outstanding claims, resolve payment variances, and achieve timely reimbursement
• Works with management to identify, trend, and address root causes of denials; helps pinpoint strategies for reducing A/R
• Maintains a thorough understanding of federal and state regulations, as well as specific payer requirements and explanations of benefits, to identify and report billing compliance issues and payer discrepancies
• Effectively handles all communications, including telephone and email, from payers and departments with the business office
• Participates in continuous quality improvement efforts on an ongoing basis, establishing goals with supervisors and tracking progress
• Demonstrates initiative and resourcefulness by making recommendations and communicating trends and issues to management
• Understand and maintains compliance with HIPAA guidelines when handling patient information
• Performs other duties as assigned
• Promote a team atmosphere by treating individuals with respect and honesty and by using direct communication and active listening skills
• Be open to change and actively support change
• Be open to others' ideas and points of view
• Evaluate employees objectively and provide employees with periodic feedback
• Promote department goals as well as the mission of the hospital
• Communicate goals to fellow staff members
• Maintain department policies and procedures
• Include requirements and guidelines from external agencies (i.e., Joint Commission, State of Wisconsin)
• Maintain and/or communicate to appropriate party function backlog at a set time
• Educate new staff regarding regulations or requirements of those functions that relate to their areas or departments, as directed
• Demonstrate acceptance and training of student interns in the department, as directed
• Participate in hospital committees, performance improvement team meetings, and team projects, as directed
• Demonstrate punctuality and preparedness
• Demonstrate effective communication skills
• Demonstrate good organizational skills
• Contribute in a positive, solution-focused manner
• Conduct self in a professional manner
• Demonstrate organizational skills that promote timely response to all inquiries and to task completion
• Communicate with all individuals in a positive and professional manner
• Attempt to resolve individual issues with peers in a positive, calm manner, with a focus on solution
• Communicate concerns and provide solutions for same
• Project a professional image by wearing appropriate, professional attire
• Ability to influence departments within Rogers and provide technical guidance

Physical and mental demands

• This role primarily involves sedentary work, requiring the employee to sit for extended periods. Occasional walking, standing, or reaching may be necessary to retrieve materials or operate office equipment
• Lifting is moderate; must be capable of lifting a minimum of twenty (20) pounds
• Reaching, handling, grasping and manual dexterity are necessary to operate various equipment
• Verbal and hearing ability are required to interact with staff, consultants, patients and family members of patients
• Numerical ability is required to maintain records and operate a computer
• Tact is required to interact effectively with employees and professional staff
• Logical thinking and discretion required to make decisions in initiating and implementing policies and procedures and standards
• Must be able to read and communicate through written, verbal and auditory skills and abilities
• Must be physically/mentally able to perform job duties as verified by a physical exam by a licensed physician, per post-employment physical

Education and training requirements

• High school diploma or equivalent required
• Minimum of one year of relevant experience in mental health or medical insurance billing and/or collections required
• Demonstrated knowledge of and experience with third-party payer guidelines, reimbursement, follow-up, and collections
• Demonstrated knowledge of claims review and analysis; ICD-10, CPT, and HCPCS coding; and medical terminology
• Effective communication, leadership, organizational, and problem-solving skills
• Ability to manage multiple tasks and projects simultaneously
• Ability to analyze data, identify improvement, and implement change
• Strong interpersonal and customer service skills
• Proficiency with Microsoft Word, Excel, Outlook, Teams, OneNote and Oracle Health Patient Accounting systems
• Ability to work quickly and effectively in a fast-paced detail-oriented environment while adhering to deadlines

Benefits

• Health, dental, and vision insurance coverage for you and your family
• 401(k) retirement plan
• Employee share program
• Life/disability insurance
• Flex spending accounts
• Tuition reimbursement
• Health and wellness program
• Employee assistance program (EAP)